Spotlight Case March 2008 - PowerPoint PPT Presentation

Spotlight Case March 2008. Back Again. Source and Credits. This presentation is based on the March 2008 AHRQ WebM&M Spotlight Case See the full article at http://webmm.ahrq.gov CME credit is available Commentary by: Jon D. Lurie , MD, MS Dartmouth Medical School

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A 34-year-old man came to the emergency department for evaluation of low back pain. He stated that the pain had been present for about one week and that he had an isolated episode of fever, which resolved with acetaminophen. Past medical history was significant for use of heroin and cocaine until one year earlier. Medications included methadone and ibuprofen. He had no allergies.

Physical examination revealed tachycardia and tenderness in the lumbosacral region; straight leg raising test was negative. X-ray of the lumbar spine was normal. The patient was discharged home on ibuprofen and advised to follow up with his primary physician the next day.

The patient did not see his primary physician the next day. Instead, the day after that, he went to another ED with complaints of back pain and was again advised to use ibuprofen and follow up with his primary physician. The patient returned to the hospital again after 4 days with complaints of worsening back pain and new shortness of breath. Examination revealed bilateral rales, a systolic murmur in the mitral area, and track marks over flexor aspects of both upper extremities.

Shortly after admission, the patient developed acute respiratory failure requiring intubation. He became hypotensive and laboratory results were significant for the presence of bandemia, thrombocytopenia, coagulopathy, acute renal insufficiency, and micro- and macro-hematuria. He was treated with fluid resuscitation, antibiotics, fresh frozen plasma, and platelets. Despite these efforts, the patient developed bleeding from his venipuncture sites, oral cavity, and rectum, along with refractory hypotension.

Aggressive resuscitation efforts, including red cell transfusion and vasopressor therapy, were initiated, but the patient died of overwhelming shock. The patient’s cultures subsequently grew methicillin-resistant staphylococcus aureus. Autopsy revealed a 2x1 inch tricuspid valve vegetation, bilateral patchy pneumonias, and multiple bilateral cortical infarcts in the kidneys. The final cause of death was “complications of infective endocarditis.”

Important to maintain proper vigilance for potentially “dangerous” causes of low back pain without performing unnecessary diagnostic work-ups

Physicians faced with decisions of diagnostic triage of low back pain in the acute setting can follow useful, highly relevant algorithms available in the Clinical Practice Guideline on “Acute Low Back Problems in Adults”

Back pain is a common complaint in infective endocarditis, occurring in up to 43% of cases

Presenting a myriad of challenges for health care providers, injection drug users are at high risk for serious infections; therefore, extra care in the evaluation of their complaints is often warranted